Urinary incontinence for the primary care physician.

This article reviews the recent data on the etiology, evaluation, and treatment of urinary incontinence in older adults. While urinary incontinence remains a major problem for older people, many of these patients never receive medical evaluation or treatment. The nonspecialist can make substantial inroads into incontinence by identifying affected patients, treating medical causes of incontinence effectively, and evaluating bladder and urethral function using simple techniques. While many patients may need referral, the cause of incontinence in most older adults can be identified and effectively treated by nonspecialists. Behavioral methods are becoming increasingly important in this effort. In office practice, up to 80% of all patients will respond with decreases in incontinence of at least 50%. Controlled studies indicate between one third and one half of nursing home patients will be equally improved. Consequently, there is good reason for substantial optimism with this problem.

A patient-completed screening instrument for functional disability in the elderly.

PURPOSE: Although multi-disciplinary geriatric assessment of elderly patients has been shown to be effective in identifying new diagnoses and previously unknown disabilities and in decreasing hospitalization and mortality, time and financial constraints prevent most internists and office practitioners from using this approach with their older patients. Several instruments to screen older persons for functional disability have been proposed, but there are limited data regarding their utility or effectiveness in clinical medicine. This study developed a short, patient-completed screening assessment instrument (the Functional Assessment Screen), compared it to a standard, multi-disciplinary geriatric evaluation, and determined the screening instrument's ability to predict future use of home care services in a group of elderly patients. PATIENTS AND METHODS: The screening instrument was piloted retrospectively using data from patients seen in the previous 2 years at a hospital-based geriatrics clinic in Wisconsin. Using these results, a revised instrument was developed and mailed to 80 consecutive new patients who presented to the clinic for multi-disciplinary geriatric assessment and primary care. These patients were interviewed 18 months later to determine use of home services, institutionalization, and death after the initial visit. RESULTS: Fifty-eight of 80 eligible patients (72%) completed both the clinic evaluation and 18-month follow-up. The patients were an elderly (mean age of 76), frail (average of three medical diagnoses), functionally disabled group (dependent in an average of 3.7 instrumental activities of daily living and 2.7 activities of daily living). Nine of the 58 enrolled patients (15%) were institutionalized, five (9%) died, and 31 (53%) required new home services after 18 months. The screening variables were sensitive but less specific than clinic providers' judgment in identifying abnormalities in social, economic, or physical health status. The relative risk of eventual home service use was elevated in patients reporting poor health status (relative risk of 3.5, 95% confidence interval [CI] 9.9 to 1.2), and dependency in housework (relative risk of 3.0, 95% CI 5.1 to 1.7), shopping (relative risk of 2.6, 95% CI 4.7 to 1.5), meals (relative risk of 2.4, 95% CI 3.4 to 1.7), dressing (relative risk of 2.2, 95% CI 3.0 to 1.6), or bathing (relative risk of 2.2, 95% CI 3.2 to 1.5). Home services were used in 16% of patients with no positive responses to a subset of four of the screening questions; usage rose to 22% with one positive response, and to 89% (relative risk of 4.5, 95% CI 9.2 to 2.1) with two or more positive responses. CONCLUSIONS: This screening instrument identified a group of elderly patients at much higher risk for increased home service use than other patients in a geriatrics clinic. If validated in other populations, such an instrument may identify frail, elderly patients in office practice at high risk for use of home services. These patients could be targeted for more complete multi-disciplinary geriatric assessment to identify and treat disease and disability responsible for increased service use and declining health.

A simple procedure for general screening for functional disability in elderly patients.

We propose a short, simple approach that can be used by general internists to routinely screen the functional status of elderly patients in office practice. The approach relies on checking a limited number of targets that are commonly dysfunctional but often unappreciated when conventional histories and physical examinations are done for elderly patients. The new focus is on carefully selected tests of vision, hearing, arm and leg function, urinary incontinence, mental status, instrumental and basic activities of daily living, environmental hazards, and social support systems. Brief questions and easily observed tasks are used to obtain the information needed for a suitable, effective screening while minimizing the time for administration. The approach can be incorporated into routine practice if certain relatively unproductive procedures are eliminated from the routine clinical examination, and particularly if internists are suitably compensated for the additional time.

Practical management of urinary incontinence.

A comprehensive evaluation of incontinence using office-based techniques may discover reversible problems such as delirium, urinary infections, vaginitis, depression, drug effects, endocrinologic causes, immobility, or impaction. Treatment of these causes may alleviate incontinence. Bedside urodynamics are a sensitive, specific, and useful office-based technique that can identify detrusor instability, overflow incontinence, or stress incontinence. Low urinary flow rate, difficulty with catheterization, slow bladder filling or severe urgency, bladder capacity over 600 ml, and post-void residual over 150 ml need referral. Patients with hematuria, recurrent infections, recent surgery or pelvic irradiation, and pelvic or prostatic masses also need further evaluation. A number of medical and behavioral therapies are available for stress incontinence and detrusor instability that can substantially reduce incontinence, but most patients with overflow have more complicated problems requiring further evaluation, surgery, or long-term bladder drainage.

Evaluation and treatment of urinary incontinence in long term care.

All elderly patients with established urinary incontinence residing in an intermediate care facility during one year were evaluated for medical and urological conditions contributing to the incontinence; treatment was initiated for all diagnosed problems if possible. Unstable detrusor function (65%), sphincter weakness (13%), and overflow incontinence (10%) were all frequent urological causes, although several patients required extensive testing in addition to cystometrics to establish a complete diagnosis. Frequent nonurological causes of incontinence included behavioral problems (53%), immobility (45%), medication problems (24%), diabetes (18%), and local pathology (47%). Thirty-seven percent had three or more conditions identified. Treatment aimed at nonurological causes was more successful in ameliorating incontinence than urological medication; side effects were significant limitations to urological treatment success. Of the 22 patients who completed evaluation, treatment, and follow-up, five patients (23%) were cured, three (14%) showed at least a 65% decrease in incontinence, four (18%) showed at least a 30% decrease in incontinence, and 10 (45%) showed no change or worsened. We conclude that nonurological problems frequently contribute to urinary incontinence in long term care facilities; incontinence in some of these patients can be improved without urological therapy. Nonurological problems need careful definition and treatment; patients whose incontinence persists require comprehensive urological evaluation and therapy. A complete solution to incontinence in this setting may require safer drugs and better understanding of urinary pathophysiology.

Assessment and care of the community-dwelling Alzheimer's disease patient.

A two-year study of 159 community dwelling Alzheimer's disease (AD) patients evaluated in a geriatric clinic is reported. Patients were not as disabled as commonly supposed, having only a moderate reduction in cognitive function (Folstein mean Mini-Mental Status [MMS], 15.3) and physical activities of daily living (PADL), mean, 3.3, but were more dependent in their instrumental activities of daily living (IADL), mean, 1.9. Associated medical problems averaged 3.4 per patient. Forty-seven percent lived alone and 39% had not been out of the home in the previous week, making isolation a major concern. During the study, 34% went into nursing homes. Initial mean MMS of these patients was 12.4 compared to 16.6 for patients who remained at home, but activities of daily living (ADL) mean scores were not significantly different. Based on this assessment, the management of AD patients, including medication use, daycare, education and support for family caregivers, and nursing home placement, is discussed.

Urinary incontinence in the elderly: physiology, pathophysiology, diagnosis, and treatment.

Urinary incontinence is a problem affecting 5% of 10% of the elderly in the community and up to 50% of the elderly in institutions. Despite complex factors governing normal micturition, the causes of urinary incontinence can be classified into detrusor instability, overflow incontinence, sphincter insufficiency, functional illness, and iatrogenic causes. An accurate pathophysiologic diagnosis is a prerequisite to successful treatment. A decision sequence is presented to help design a reasonable diagnostic approach. With appropriate therapy, most incontinent elderly patients can expect significant improvement or cure.